Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham2The Center for Surgical, Medical Acute Care Research, and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, Alabama.
Department of Surgery, VA Boston Health Care System, Boston University and Harvard Medical School, Boston, Massachusetts.
JAMA Surg. 2016 Feb;151(2):139-45. doi: 10.1001/jamasurg.2015.3420.
Although liberal blood transfusion thresholds have not been beneficial following noncardiac surgery, it is unclear whether higher thresholds are appropriate for patients who develop postoperative myocardial infarction (MI).
To evaluate the association between postoperative blood transfusion and mortality in patients with coronary artery disease and postoperative MI following noncardiac surgery.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study involving Veterans Affairs facilities from January 1, 2000, to December 31, 2012. A total of 7361 patients with coronary artery disease who underwent inpatient noncardiac surgery and had a nadir postoperative hematocrit between 20% and 30%. Patients with significant bleeding, including any preoperative blood transfusion or transfusion of greater than 4 units during the intraoperative or postoperative setting, were excluded. Mortality rates were compared using both logistic regression and propensity score matching. Patients were stratified by postoperative nadir hematocrit and the presence of postoperative MI.
Initial postoperative blood transfusion.
The 30-day postoperative mortality rate.
Of the 7361 patients, 2027 patients (27.5%) received at least 1 postoperative blood transfusion. Postoperative mortality occurred in 267 (3.6%), and MI occurred in 271 (3.7%). Among the 5334 patients without postoperative blood transfusion, lower nadir hematocrit was associated with an increased risk for mortality (hematocrit of 20% to <24%: 7.3%; 24% to <27%: 3.7%; and 27% to 30%: 1.6%; P < .01). In patients with postoperative MI, blood transfusion was associated with lower mortality, for those with hematocrit of 20% to 24% (odds ratio, 0.28; 95% CI, 0.13-0.64). In patients without postoperative MI, transfusion was associated with significantly higher mortality for those with hematocrit of 27% to 30% (odds ratio, 3.21; 95% CI, 1.85-5.60).
These findings support a restrictive postoperative transfusion strategy in patients with stable coronary artery disease following noncardiac surgery. However, interventional studies are needed to evaluate the use of a more liberal transfusion strategy in patients who develop postoperative MI.
虽然非心脏手术后放宽输血阈值对患者没有益处，但对于发生术后心肌梗死（MI）的患者，更高的阈值是否合适仍不清楚。
评估非心脏手术后冠状动脉疾病和术后 MI 患者的术后输血与死亡率之间的关系。
设计、设置和参与者：这是一项回顾性队列研究，涉及 2000 年 1 月 1 日至 2012 年 12 月 31 日期间的退伍军人事务部设施。共有 7361 例接受住院非心脏手术且术后最低血细胞比容在 20%至 30%之间的冠状动脉疾病患者。排除有明显出血的患者，包括任何术前输血或术中或术后输血超过 4 单位。使用逻辑回归和倾向评分匹配比较死亡率。根据术后最低血细胞比容和术后 MI 的存在对患者进行分层。
初始术后输血。
30 天术后死亡率。
在 7361 例患者中，有 2027 例（27.5%）接受了至少 1 次术后输血。有 267 例（3.6%）发生术后死亡，有 271 例（3.7%）发生 MI。在未接受术后输血的 5334 例患者中，较低的最低血细胞比容与死亡率增加相关（血细胞比容 20%至<24%：7.3%；24%至<27%：3.7%；27%至 30%：1.6%；P<.01）。在发生术后 MI 的患者中，对于血细胞比容为 20%至 24%的患者，输血与较低的死亡率相关（比值比，0.28；95%CI，0.13-0.64）。在没有发生术后 MI 的患者中，对于血细胞比容为 27%至 30%的患者，输血与显著更高的死亡率相关（比值比，3.21；95%CI，1.85-5.60）。
这些发现支持在非心脏手术后稳定型冠状动脉疾病患者中采用限制性术后输血策略。然而，需要进行干预性研究来评估在发生术后 MI 的患者中采用更宽松的输血策略的效果。
